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CONTROL OF ANTICOAGULANT THERAPY
279 INDUCTION OF ANAESTHESIA IN YOUNG CHILDREN
SIR,-Dr. Hodges’ thoughtful article (Jan. 9) is of interest to all who have the handling of children at heart. The difficulty in all this work is to devise an absolute standard of behaviour pattern. Doughty1 first drew attention to this need, and he has done much work since. Using a similar classification to his I did a controlled series of 100 cases, comparing premedication with atropine only, with a methylpentynol/hyoscine mixture given by mouth. A summary of my results was:
I still feel that
should help the "self-controlled but of Dr. Hodges, provided this can be guarded" done with safety, and for this purpose I still find the methylpentynol/hyoscine mixture valuable. Recent correspondence in the Medical Journal of Australia 2-5 again raised the matter of the incidence of vomiting during induction after premedication with methylpentynol in the form of ’Oblivon ’ elixir. we
cases
Rendell,6 in the first article
on the clinical use of methyltenth of the cases induction ... was delayed by vomiting ". It is unfortunate that this statement has been copied many times, including in the new textbook on anaesthetics by Wylie and Churchill-Davidson, because on closer reference to Rendell’s article it is stated that " though normally premedication was given 1 hour before operation, half to 2 hours or more proved satisfactory ". In my original article,7 in which I quote from over 500 cases, I stated that "... no difficulty from vomiting on induction has been observed. I think the difference in my series is due to the fact that the methylpentynol had been given at least 1 hour before induction ". I. R. McDonald statedthat he passed a Ryle’s tube on 4 successive cases premedicated with this drug and that the minimum volume aspirated was 8 oz. (230 ml.). This obviously needed verification. During routine tonsil lists I therefore passed a small plastic oesophageal tube under direct vision after the patient had been induced and was on the table with the Boyle-Davis gag in position. The presence of the tube in the stomach was confirmed by auscultation over the
pentynol,
did state " in about
eniQ"atril1m. The following
a
were mv
rpsnit’
In no case was the stomach aspirated less than 1½ hours after the premedication: this I am sure is the secret of success with this method. The hyoscine is dissolved in the methylpentynol so that no preoperative injection of atropine is necessary. I still find this a very safe and satisfactory premedication for children. F. R. GUSTERSON. Worthing.
few reflections the effects of hospital on
SIR,-Dr. Hodges’ article prompts from me. As
an
early worker on
a
Brit. J. Anœsth. 1957, 29, 407. McDonald, I. H. Med.J. Aust. 1959, ii, 417. 3. McDonald, I. R. ibid. p. 541. 4. McDonald, I. H. ibid. p. 740. 5. Gusterson, F. R. ibid. p. 829. 6. Rendell, C. M. Brit. med. J. 1954, ii, 1397. 7. Gusterson, F. R. Lancet, 1955, i, 940. 1. 2.
young children I noted that " the operation for the removal of tonsils seems to be very traumatic, out of all proportion to its severity ".1 It was therefore very reassuring to note how, with modern methods, the trauma of the anxsthesia and the surgery could be reduced to a minimum. I was the more interested however in Dr. Hodges’ other finding-namely, that " factors other than anaesthesia may be more often responsible for psychic trauma ", and he specifically mentions homesickness. This would correspond to the psychiatrists’ " emotional insecurity " (or overdependence) a feeling which, as explained in my monograph, is the key to the whole problem of hospitalisation. One does not so much ask for special methods in hospital; I take it for granted that every effort is made to minimise the unpleasantness of the procedures there. But one must always be prepared to find a few children for whom the hospitalisation itself is the distressing experience. These are the potential cases of neurosis and may need added or special attention. The of children, with normal sympathetic handling, majority " digest " and overcome the experience: not so these few who fail on account of some inner problem making them the more 1:n11np’t’"hlp-
H. EDELSTON.
Leeds.
CONTROL OF ANTICOAGULANT THERAPY
SiR,-Dr. Matthews and Dr. Walker (Dec. 26), referring to the one-stage prothrombin-time, state: " It is
pathologists and hospital doctors in general who, despite its theoretical and practical shortcomings, have confidence in the method and find it tolerably safe." Such a statement impugns not merely the reliability of the original test but also that of other procedures, especially the thromboplastin generation test, since the last step in the latter method is essentially a onestage prothrombin-time. What are the theoretical shortcomings ? familiar
to
clinical
The one most commonly cited is that a prolonged prothrombin-time is generally not due to a decrease of prothrombin. When the test was developed, such factors as thromboplastin and prothrombin were recognised primarily as activities, and it was found by both the one- and two-stage methods that the level of prothrombin in the blood markedly dropped in vitamin-K deficiency and after the administration of dicoumarin. With the observation2 that the delayed prothrombin-time of stored oxalated human plasma could be completely corrected by the addition of fresh plasma depleted of prothrombin by adsorption with Al(OH)3 or plasma from an animal given dicoumarin, it became evident that the test was also sensitive to a new clotting factor hitherto unrecognised. It is now established that the test is not only sensitive to this factor (labile or v) but also to stable factor (vn) and to the less well-defined Stuart-Prower factor. By adding to the patient’s plasma a minute amount of labile factor in the form of deprothrombinised rabbit plasma, the prolonged prothrombin-time in congenital labile-factor deficiency is corrected to the normal of 12 seconds. Likewise, the prothrombin-time is corrected to 12 seconds by the addition of normal aged serum in stable and in Stuart-Prower deficiency. Only in true hypoprothrombinxmia is there no correction effected by either adsorbed rabbit plasma or aged serum. Thus, by simple modifications of the one-stage method, it can be made specific for any of the known factors in the prothrombin complex. What is called a shortcoming is actually a pillar of
strength. The newly alleged shortcoming-namely, that it is sensitive to the contact factor-would, no doubt, be serious if we had glass-lined blood-vessels. Interestingly, Matthew and Walker found a good correlation between the thrombotest and the Quick test while the correlanot
"
1. 2.
Edelston, H. Separation Anxiety in Young Children. Genetic Psychology Monographs, 1942. Quick, A. J. Amer. J. Physiol. 1943, 140, 212.
280 tion between thrombotest and the p & p test was not quite so good ". Yet, only a relatively short time ago, the latter test was introduced as a much superior test to the basic one-stage method. The logic of how all this is likely to " confirm it (thrombotest) as the best laboratory procedure for the control of anticoagulation therapy " is somewhat elusive. Department of Biochemistry, Marquette University School of Medicine, ARMAND J. QUICK. Milwaukee, Wisconsin.
CHROMOSOME STUDIES IN LEUKÆMIA SiR,-The calculations for 8 cases of chronic leukaemia (3 myeloid and 3 lymphatic) referred to in our letter of Jan. 16 are shown in the accompanying table. DISTRIBUTION OF CHROMOSOMES COUNTS IN CHRONIC LBUKAMIA
Medical Research Council Group for Research on the General Effects of Radiation, Western General Hospital,
Edinburgh.
A. G. BAIKIE W. M. COURT BROWN PATRICIA A. JACOBS.
NATURAL HISTORY OF CAVERNOUS HÆMANGIOMATA
SIR,-We are discussing a very little understood condition, which in some ways might be classed with congenital deformities, and in others with new growths. May I suggest "
a name
for it which I have used for many years-
spreading angioma of infancy " ? Naevus is a meaningless term, including stains and moles; strawberry " as an adjective applies only to minor degrees; and there is nothing in them resembling caverns. But they do belong to the vast and varied group of angiomata, they do grow, and this growth does occur in infancy. I wrote about one stage in the natural history of one the
"
Fig.1 Started tissue.
as
Fig.
general surgeon. As to other methods of treatment, I dislike X rays, though they are undoubtedly effective during the period of rapid growth. Carbon-dioxide snow is obviously completely futile on any but the very superficial types which are best left alone. A primary excision is often the best as well as the most obvious treatment; it saves the mother years of embarrassment, and in
Fig. 3
2
stage of full growth, and beginning regression. small spot, will end as mass of redundant fibrous
Fig. 1-Angioma
type of these angiomata, the small but growing spot on the face which appears at or soon after birth. They are often described by the mothers, who alone at this stage worry about them, as having started like a gnat-bite or a little scratch. They are seen by general practitioners, doctors - in clinics, pxdiatricians, and obstetricians; but I have never known them at this stage to be referred to dermatologists or plastic surgeons. This correspondence has made it clear what would happen if they were. What they are apt to grow into is shown by the accompanying photographs, and the question I raised was whether this horrible development could be stopped. It must be clearly understood that it is not treatment at the stage illustrated which I am discussing, but treatment to avoid its occurrence. On the comparatively rare occasions on which I find these growing red spots I have been treating them by subcutaneous injections of saturated salt (sodium chloride) solution, which is non-toxic but extremely caustic; if injected into the skin it will cause a slough. I get the impression that the violent cellular reaction produced in the deep tissues by this will begin the process of regression; at any rate none treated in this way has run wild as they so often do if left alone. Supposing one were to get a hundred of these "’ surgical emergencies "-the growing red spots on the face-treat them with these injections, and find that there were no disfigurements of the kind shown, one would have some interesting though inconclusive information. It would be inconclusive because it would be impossible to prove what would have happened had nothing been done; but then so much medical information is of this type. I have also been pleased with the results of injecting comparatively large quantities, up to 5 ml., into that type of angioma which closely mimics a rapidly growing sarcoma of the face; a deep elastic swelling with a faint blue tinge, under skin which at first is intact. This type again is not referred to dermatologists or plastic surgeons; it sets difficult problems of diagnosis and treatment to the
at
Fig. 3--Similar case to figs. 1 and 2, showing a more advanced stage of regression, with a baggy sear of the cheek.
Fig. 2-Similar
case
Fig. 4 to
fig.
1.
Fig. 4-An angioma at the stage of rapid growth, showing many points at the gnat-bite stage. It is obvious that bad scarring will result, and excision of the redundant tissues of the lip be "
necessary.
"
SIR,-Dr. Hodges’ thoughtful article (Jan. 9) is of interest to all who have the handling of children at heart. The difficulty in all this work is to devise an absolute standard of behaviour pattern. Doughty1 first drew attention to this need, and he has done much work since. Using a similar classification to his I did a controlled series of 100 cases, comparing premedication with atropine only, with a methylpentynol/hyoscine mixture given by mouth. A summary of my results was:
I still feel that
should help the "self-controlled but of Dr. Hodges, provided this can be guarded" done with safety, and for this purpose I still find the methylpentynol/hyoscine mixture valuable. Recent correspondence in the Medical Journal of Australia 2-5 again raised the matter of the incidence of vomiting during induction after premedication with methylpentynol in the form of ’Oblivon ’ elixir. we
cases
Rendell,6 in the first article
on the clinical use of methyltenth of the cases induction ... was delayed by vomiting ". It is unfortunate that this statement has been copied many times, including in the new textbook on anaesthetics by Wylie and Churchill-Davidson, because on closer reference to Rendell’s article it is stated that " though normally premedication was given 1 hour before operation, half to 2 hours or more proved satisfactory ". In my original article,7 in which I quote from over 500 cases, I stated that "... no difficulty from vomiting on induction has been observed. I think the difference in my series is due to the fact that the methylpentynol had been given at least 1 hour before induction ". I. R. McDonald statedthat he passed a Ryle’s tube on 4 successive cases premedicated with this drug and that the minimum volume aspirated was 8 oz. (230 ml.). This obviously needed verification. During routine tonsil lists I therefore passed a small plastic oesophageal tube under direct vision after the patient had been induced and was on the table with the Boyle-Davis gag in position. The presence of the tube in the stomach was confirmed by auscultation over the
pentynol,
did state " in about
eniQ"atril1m. The following
a
were mv
rpsnit’
In no case was the stomach aspirated less than 1½ hours after the premedication: this I am sure is the secret of success with this method. The hyoscine is dissolved in the methylpentynol so that no preoperative injection of atropine is necessary. I still find this a very safe and satisfactory premedication for children. F. R. GUSTERSON. Worthing.
few reflections the effects of hospital on
SIR,-Dr. Hodges’ article prompts from me. As
an
early worker on
a
Brit. J. Anœsth. 1957, 29, 407. McDonald, I. H. Med.J. Aust. 1959, ii, 417. 3. McDonald, I. R. ibid. p. 541. 4. McDonald, I. H. ibid. p. 740. 5. Gusterson, F. R. ibid. p. 829. 6. Rendell, C. M. Brit. med. J. 1954, ii, 1397. 7. Gusterson, F. R. Lancet, 1955, i, 940. 1. 2.
young children I noted that " the operation for the removal of tonsils seems to be very traumatic, out of all proportion to its severity ".1 It was therefore very reassuring to note how, with modern methods, the trauma of the anxsthesia and the surgery could be reduced to a minimum. I was the more interested however in Dr. Hodges’ other finding-namely, that " factors other than anaesthesia may be more often responsible for psychic trauma ", and he specifically mentions homesickness. This would correspond to the psychiatrists’ " emotional insecurity " (or overdependence) a feeling which, as explained in my monograph, is the key to the whole problem of hospitalisation. One does not so much ask for special methods in hospital; I take it for granted that every effort is made to minimise the unpleasantness of the procedures there. But one must always be prepared to find a few children for whom the hospitalisation itself is the distressing experience. These are the potential cases of neurosis and may need added or special attention. The of children, with normal sympathetic handling, majority " digest " and overcome the experience: not so these few who fail on account of some inner problem making them the more 1:n11np’t’"hlp-
H. EDELSTON.
Leeds.
CONTROL OF ANTICOAGULANT THERAPY
SiR,-Dr. Matthews and Dr. Walker (Dec. 26), referring to the one-stage prothrombin-time, state: " It is
pathologists and hospital doctors in general who, despite its theoretical and practical shortcomings, have confidence in the method and find it tolerably safe." Such a statement impugns not merely the reliability of the original test but also that of other procedures, especially the thromboplastin generation test, since the last step in the latter method is essentially a onestage prothrombin-time. What are the theoretical shortcomings ? familiar
to
clinical
The one most commonly cited is that a prolonged prothrombin-time is generally not due to a decrease of prothrombin. When the test was developed, such factors as thromboplastin and prothrombin were recognised primarily as activities, and it was found by both the one- and two-stage methods that the level of prothrombin in the blood markedly dropped in vitamin-K deficiency and after the administration of dicoumarin. With the observation2 that the delayed prothrombin-time of stored oxalated human plasma could be completely corrected by the addition of fresh plasma depleted of prothrombin by adsorption with Al(OH)3 or plasma from an animal given dicoumarin, it became evident that the test was also sensitive to a new clotting factor hitherto unrecognised. It is now established that the test is not only sensitive to this factor (labile or v) but also to stable factor (vn) and to the less well-defined Stuart-Prower factor. By adding to the patient’s plasma a minute amount of labile factor in the form of deprothrombinised rabbit plasma, the prolonged prothrombin-time in congenital labile-factor deficiency is corrected to the normal of 12 seconds. Likewise, the prothrombin-time is corrected to 12 seconds by the addition of normal aged serum in stable and in Stuart-Prower deficiency. Only in true hypoprothrombinxmia is there no correction effected by either adsorbed rabbit plasma or aged serum. Thus, by simple modifications of the one-stage method, it can be made specific for any of the known factors in the prothrombin complex. What is called a shortcoming is actually a pillar of
strength. The newly alleged shortcoming-namely, that it is sensitive to the contact factor-would, no doubt, be serious if we had glass-lined blood-vessels. Interestingly, Matthew and Walker found a good correlation between the thrombotest and the Quick test while the correlanot
"
1. 2.
Edelston, H. Separation Anxiety in Young Children. Genetic Psychology Monographs, 1942. Quick, A. J. Amer. J. Physiol. 1943, 140, 212.
280 tion between thrombotest and the p & p test was not quite so good ". Yet, only a relatively short time ago, the latter test was introduced as a much superior test to the basic one-stage method. The logic of how all this is likely to " confirm it (thrombotest) as the best laboratory procedure for the control of anticoagulation therapy " is somewhat elusive. Department of Biochemistry, Marquette University School of Medicine, ARMAND J. QUICK. Milwaukee, Wisconsin.
CHROMOSOME STUDIES IN LEUKÆMIA SiR,-The calculations for 8 cases of chronic leukaemia (3 myeloid and 3 lymphatic) referred to in our letter of Jan. 16 are shown in the accompanying table. DISTRIBUTION OF CHROMOSOMES COUNTS IN CHRONIC LBUKAMIA
Medical Research Council Group for Research on the General Effects of Radiation, Western General Hospital,
Edinburgh.
A. G. BAIKIE W. M. COURT BROWN PATRICIA A. JACOBS.
NATURAL HISTORY OF CAVERNOUS HÆMANGIOMATA
SIR,-We are discussing a very little understood condition, which in some ways might be classed with congenital deformities, and in others with new growths. May I suggest "
a name
for it which I have used for many years-
spreading angioma of infancy " ? Naevus is a meaningless term, including stains and moles; strawberry " as an adjective applies only to minor degrees; and there is nothing in them resembling caverns. But they do belong to the vast and varied group of angiomata, they do grow, and this growth does occur in infancy. I wrote about one stage in the natural history of one the
"
Fig.1 Started tissue.
as
Fig.
general surgeon. As to other methods of treatment, I dislike X rays, though they are undoubtedly effective during the period of rapid growth. Carbon-dioxide snow is obviously completely futile on any but the very superficial types which are best left alone. A primary excision is often the best as well as the most obvious treatment; it saves the mother years of embarrassment, and in
Fig. 3
2
stage of full growth, and beginning regression. small spot, will end as mass of redundant fibrous
Fig. 1-Angioma
type of these angiomata, the small but growing spot on the face which appears at or soon after birth. They are often described by the mothers, who alone at this stage worry about them, as having started like a gnat-bite or a little scratch. They are seen by general practitioners, doctors - in clinics, pxdiatricians, and obstetricians; but I have never known them at this stage to be referred to dermatologists or plastic surgeons. This correspondence has made it clear what would happen if they were. What they are apt to grow into is shown by the accompanying photographs, and the question I raised was whether this horrible development could be stopped. It must be clearly understood that it is not treatment at the stage illustrated which I am discussing, but treatment to avoid its occurrence. On the comparatively rare occasions on which I find these growing red spots I have been treating them by subcutaneous injections of saturated salt (sodium chloride) solution, which is non-toxic but extremely caustic; if injected into the skin it will cause a slough. I get the impression that the violent cellular reaction produced in the deep tissues by this will begin the process of regression; at any rate none treated in this way has run wild as they so often do if left alone. Supposing one were to get a hundred of these "’ surgical emergencies "-the growing red spots on the face-treat them with these injections, and find that there were no disfigurements of the kind shown, one would have some interesting though inconclusive information. It would be inconclusive because it would be impossible to prove what would have happened had nothing been done; but then so much medical information is of this type. I have also been pleased with the results of injecting comparatively large quantities, up to 5 ml., into that type of angioma which closely mimics a rapidly growing sarcoma of the face; a deep elastic swelling with a faint blue tinge, under skin which at first is intact. This type again is not referred to dermatologists or plastic surgeons; it sets difficult problems of diagnosis and treatment to the
at
Fig. 3--Similar case to figs. 1 and 2, showing a more advanced stage of regression, with a baggy sear of the cheek.
Fig. 2-Similar
case
Fig. 4 to
fig.
1.
Fig. 4-An angioma at the stage of rapid growth, showing many points at the gnat-bite stage. It is obvious that bad scarring will result, and excision of the redundant tissues of the lip be "
necessary.
"